Air ambulance transports can put patients at financial risk, says GAO

Air ambulance transports in the United States can leave privately insured patients on the hook for tens of thousands of dollars, a new report from the Government Accountability Office (GAO) confirms.

The report explores the phenomenon of balance billing in the U.S. air medical industry, in which an out-of-network provider goes after a patient for the amount of a bill not covered by the insurer. While providers are prohibited from sending balance bills to Medicare and Medicaid patients, no such protections extend to privately insured patients.

According to the GAO, skyrocketing billed charges in the air medical industry have exacerbated the financial risk to these patients. Between 2012 and 2017, the median price charged for a helicopter transport increased from $22,100 to $36,400, while the median price for a fixed-wing transport rose from $24,900 to $40,600 — jumps of more than 60 percent.

Given such high sticker prices, the associated balance bills can also be steep. As part of a study commissioned by Congress, the GAO analyzed 60 relevant consumer complaints from two states. Of those, all but one of the balance bills was for more than $10,000, with the largest balance bill exceeding $60,000.

The GAO noted that the extent to which patients actually pay the full amounts of the balance bills is unclear, since air ambulance providers first encourage patients to appeal to their insurers for increased payment. If that is unsuccessful in fully addressing the bill, then providers may offer various payment options, sometimes requiring patients to share detailed information about their financial status.

“Air ambulance providers we spoke with said that they use discretion on how much assistance to offer, and not all patients receive discounts after providing all relevant documentation,” the GAO report states. “Even with discounts, according to data from some air ambulance providers we spoke with, the amount patients pay can still be in the thousands of dollars.”

The GAO estimated that around 69 percent of air ambulance transports of privately insured patients were out-of-network in 2017. That’s considerably higher than what previous research has estimated for ground ambulance transports (around 51 percent) and other emergency services.

The report suggests that, compared to other types of health care services, “the emergency nature of most air ambulance transports, as well as their relative rarity and high prices charged, reduces the incentives of both air ambulance providers and insurers to enter into contracts with agreed-upon payment rates.”

While some states — including Montana and North Dakota — have attempted to regulate balance billing by out-of-network air ambulance providers, their efforts have been challenged under the Airline Deregulation Act, which preempts states from regulating the rates, routes, and services of air carriers. Nevertheless, officials in both states reported receiving fewer consumer complaints after their laws were enacted, with officials in Montana noting that “uncertainty over the possible effects of the law has made most air ambulance providers more willing to enter into contract negotiations with insurers.”

Additionally, some air ambulance providers who spoke with the GAO reported that they have recently been entering into more network contracts. For example, in August 2018, Air Methods and Anthem announced an in-network agreement covering Anthem consumers in five states: Indiana, Kentucky, Missouri, Ohio, and Wisconsin. “These contracts could decrease the extent of out-of-network transports and balance billing in the future for these states,” the report observes.

The GAO also noted that the Secretary of Transportation is in the process of forming an advisory committee on air ambulance patient billing, as required by the FAA Reauthorization Act of 2018. The committee will make recommendations on topics including options and best practices for preventing balance billing, steps that states can take to protect consumers, and the disclosure of charges and fees for air ambulance services.

The GAO’s latest report on the air ambulance industry follows one it released in 2017, when the agency noted that it lacked information necessary to determine the prevalence of balance billing. This time around, the GAO was still unable to make firm conclusions in that respect, as “there is a lack of comprehensive national data about the extent and size of balance bills, and air ambulance providers are generally not required to report such data.”

With its 2017 report, the GAO made four recommendations to the Department of Transportation (DOT). According to its latest report, the DOT has taken steps to respond to two of these recommendations: communicating a method to receive air ambulance complaints, and taking steps to make complaint information publicly available.

However, the DOT has not yet acted on the remaining two recommendations: determining what information could assist in the evaluation of future complaints, and considering consumer disclosure requirements for air ambulance providers, including the prices they charge and the extent to which they contract with insurers.